A recent report published in the Journal of the American Medical Association confirms what many observers of the US health care system have been reporting anecdotally for quite some time – policy changes at the Educational Commission for Foreign Medical Graduates (ECFMG) are having a dramatic impact on the size and profile of the pool of international medical graduates (“IMGs”) in the United States. And since IMGS have over the last several decades consistently represented one fourth of both the physician workforce and the graduate medical education (GME) population of the United States, these changes will soon have a dramatic effect on Americans’ access to health care.
The ECFMG is the organization that certifies IMGS seeking to enter the US to participate in medical residency and other clinical training programs in the US. Until 1998, physicians seeking to enter the US needed to show that they graduated from a medical school listed in the World Director of Medical Schools and achieve passing scores on the US Medical Licensing Exam (USMLE) Step 1 (basic science) and USMLE Step 2 (clinical science) as well as the Test of English as a Foreign Language (TOEFL).
In 1998, ECFMG added the requirement of achieving a passing score on the ECFMG Clinical Skills Assessment (CSA). The logic behind adding the exam was to address the concern that medical students were not graduating with sufficient basic clinical skills to succeed in US residency programs. The CSA is a performance assessment that requires IMGs to show that they can gather and properly interpret patient information and communicate their findings at a level comparable to or higher than students graduating from US and Canadian medical schools. The exam is fairly exhaustive – candidates must go through ten exercises where they interact with patients in English and compose case notes. Right now, the CSA is only offered in Philadelphia, Pennsylvania. As of September 23rd of this year, the CSA is also being offered in Atlanta, Georgia. Currently, there are no announced plans to offer the exam outside the United States.
The AMA’s team of researchers examined ECFMG databases and found that there has been a tremendous drop in the number of IMGs training in the US over the last few years. The ECFMG issued between 9,000 and 12,000 certificates between 1995 and 1998, but fewer than 6,000 certificates were issued in 1999, 2000, and 2001. The study also showed a 58% drop from 1995 to 2001 in the number of international medical graduate registrations for the USMLE Step 1 and Step 2 examinations. Passage of both of these exams is a prerequisite to getting an ECFMG certificate.
The report noted that there have been no changes in the geographical distribution of those registering for the USMLE exams. About 3/4 of the applicants who graduated from non-US medical schools have been from the United States, Canada and Europe since 1996 with few changes in the proportionate breakdown. Registrants from Asia ranged from 13 to 15 percent during the same time period.
The passage rate for the USMLE exams is rising for international medical graduates. The rate of passage for Step 1 went up from 57.6% in 1997 to 68.3% in 2001. For Step 2, the passage rate went up from 53% to 80% during the same time period. The passage rate for the CSA exam has dropped since the exam was introduced four years ago, but is still better then 80%. The ECFMG reports that the number of CSA examinations is on the rise. In 1999, the number of registrants was 1,949. In 2002, the number had risen to 7,196.
Nevertheless, the overall number of certificates issued has declined dramatically. According to the research team at the AMA, there are several potential causes all related to the CSA:
- many international medical graduates have little or no experience with a performance assessment examination such as the CSA
- the CSA is only offered in Philadelphia which means traveling to the site is expensive and requires visas (which are often being denied)
- the CSA exam fee is $1200, which is very significant for many applicants and makes pursuing graduate medical training in the US less attractive.
It is still not clear how much the increase in the number of applicants taking the CSA exam will make up for the drop in the issuance of ECFMG certificates. If the drop is not reversed, however, the impact on the health care system in the US could be serious since there is an overall shortage of physicians in the US particularly in certain specialties and in rural areas
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